The scope of the international refugee crisis and challenges for Primary Care

Fern R. Hauck is Professor of Family Medicine and Public Health Sciences at the University of Virginia. Dr Hauck will be speaking at the forthcoming North American Primary Care Research Group (NAPCRG) annual meeting.

The scope of the crisis is staggering! The number of people displaced by war, conflict or persecution has hit a record high—over 65 million with 21 million of these being refugees. Most face an uncertain future. Those who are resettled to a developed country are among the lucky ones. Nonetheless, they face many challenges in their new home, including accessing culturally sensitive health care.

My involvement with refugees began on the Thai-Cambodian border, where I spent a year providing primary health care to Cambodian refugees who were living in the largest border camp, having fled there after the Khmer Rouge were ousted after years of genocide. Moving to Charlottesville, Virginia, in 2000, I never expected to find that refugees were being resettled in this small city. Learning that the International Rescue Committee (IRC) was responsible for the resettlement of about 150 refugees annually at that time (which has now increased to 300 persons a year), I approached them and the local health department to discuss developing a collaboration to ensure that all the new arrivals would have a medical home. The International Family Medicine Clinic (IFMC) has now been in place since 2002, and we have served more than 3,000 patients from over 30 countries.

Over the years, the IFMC has evolved and grown, as we continue to learn about our refugee patients and their needs, as well as identifying many unanswered questions leading to a variety of research and quality improvement projects. The majority of refugees have had limited access to health care prior to their arrival in the US or other developed country and most of the care they have received was for acute, infectious illnesses. In addition to the full range of acute and chronic conditions one sees in any family practice, refugees often arrive with tropical diseases such as parasites or inactive TB, skin rashes, anemia and nutritional disorders, hearing and vision problems, developmental problems (children) and dental problems. Many experience mental health disorders including depression, anxiety and panic disorder, PTSD, and somatization. While most are appreciative of finally having access to excellent medical care, the challenges are numerous for both the providers and patients, including language barriers and the need for trained interpreters, cultural differences and poor health literacy, and lack of experience with chronic disease management and screening. Most refugee patients have competing demands on their time, and need to prioritize work over getting to the clinic, or they may have transportation problems or payment concerns once their federal health insurance benefits run out.

We have found that a multidisciplinary team is essential to provide care to the refugee community; our team includes a social worker, nurse care coordinator and pharmacist. We work closely with psychologists within our department and health system, and have a special arrangement with psychiatrists who see referred patients right within our clinic. Also, we meet quarterly with the health department, IRC, and other local organizations involved in providing or facilitating healthcare services for the refugees. In addition, we have cast a wider net of stakeholder engagement through “Refugee Dialogue,” which includes numerous local organizations (including a city council member, police, transportation, etc.), as well as representatives from the refugee community.

Finally, the IFMC has developed several educational opportunities for medical students and residents, including a very popular 4th year elective. Each elective student is required to research a topic of interest, and these are shared with our providers to help improve care. MPH and other students have conducted more extensive research and quality improvement projects. For example, we are about to survey patients who have been in the US for over 5 years about their ability to learn English as well as pass the US citizenship exam, and factors that helped or hindered them. Through collaboration with other refugee healthcare researchers, for example, those in NAPCRG, we anticipate better powered studies and more meaningful research to better address the needs of our growing refugee populations.

The North American Primary Care Research Group Annual Meeting is being held from November 12th to 16th 2016 in Colorado Springs, CO. CMAJ is a co-sponsor of the meeting.